Guidance on Identifying Non-Routine Cases of Hearing Loss

Transcription

1 Guidance on Identifying Non-Routine Cases of Hearing Loss Introduction: The routine adult care pathways in the UK specifically fund hearing aid fitting, but provide no financial support for supplementary or additional forms of rehabilitation, such as communication skills training, additional rehabilitation time or assistive listening devices. Many hearing impaired adults may choose, or would benefit from, additional or alternative intervention, and some are likely require a significant amount of time and resources for additional assessment and or rehabilitation. For the purposes of this document these cases are deemed to be non-routine (or complex) cases for hearing loss management. This document is intended to enable clinicians to direct hearing impaired adults along the most appropriate treatment pathway and to enable effective discussions between commissioners and Audiology professionals by identifying cases of hearing loss in adults that are likely to be unsuitable for the routine adult care pathway. The potential definitions for a non-routine case are outlined below. Presentation of these issues may arise at any point in the care pathway, whether at receipt of referral by Audiology, initial assessment, hearing aid fitting (if appropriate) or follow up. It should be noted that this document does not advise clinicians on the management of nonroutine cases, and clinicians are referred to current evidence-based practice and to the British Society of Audiology s Practice Guidance documents, particularly the Practice Guidance on Common principles of rehabilitation for adults with hearing- and/or balancerelated problems in routine audiology services [1]. The document divides complex cases into 3 types: 1. those defined by hearing loss complexity 2. those defined by co-existing or confounding conditions or other factors 3. those defined by poor outcomes following a high quality intervention, which will typically become evident during the routine pathway process. For the purpose of this document poor outcomes is defined as: Failing to meet the appropriate clinical outcomes following rehabilitation. This may include poor performance on clinical outcome measures (the clinical decision will depend on the outcome measure used), patient reports of continuing hearing difficulty and patient reports of poor satisfaction with hearing following intervention. It is acknowledged that the outcomes deemed appropriate will vary according to the nature of the hearing loss and the person s individual circumstances (For example, a person with a longstanding profound hearing loss who works and is socially active will be expected to achieve very different outcomes to someone with a mild to moderate hearing loss who is retired and lives alone with little social interaction) Page 1

2 1. Hearing Loss Complexity Condition Long term fluctuating hearing loss Precipitous, steeply sloping or Ski-slope high frequency hearing loss Severe-profound hearing loss Mixed hearing loss Asymmetrical hearing loss Unilateral hearing loss Sudden or rapid hearing loss Evidence of recruitment Hyperacusis Notes Not associated with head colds or other respiratory tract infection. For example due to Meniere s disease, autoimmune factors, or repeat ear infections. 50+dB difference across consecutive octaves at 0.5 to 4kHz. [2] Average hearing levels >70dBHL across the frequencies 250, 500, 1000, 2000, & 4000 Hz. [3] Where ac thresholds 60dBHL and air-bone gap is 30dBHL [2] As indicated by a difference in left and right bone conduction thresholds of 20dB or greater at two or more of the following frequencies: 500, 1000, 2000, 4000 Hz.. Where hearing thresholds are <20dBHL in one ear, and 20dBHL in the other. Either: a greater than 30 db deterioration in sensorineural hearing loss occurring in at least three adjacent audiometric frequencies over 72 hours or less [4] Or: Rapid onset of hearing loss or rapid deterioration in hearing. Rapid is within 90 days or less [5]. Reduced dynamic range demonstrated by plotting Uncomfortable Loudness Levels on the pure tone audiogram. Oversensitivity to everyday sounds at Page 2

3 [6] [7] moderate/everyday intensity levels Troublesome tinnitus Acoustic neuroma Hearing loss syndromes Auditory Processing Disorders Auditory Neuropathy Spectrum Disorder (ANSD) Considered by the sufferer to be moderately or severely distressing, and which may be associated with sleep disturbance or with symptoms of anxiety or depression. [5] Diagnosed by ENT or Neurology Diagnosed by ENT, eg Usher s syndrome. Characterised by poor perception of both speech and nonspeech sounds [8]. Diagnosed using pure tone audiometry, otoacoustic emission and auditory brainstem response testing. May be identified as part of a neurological disorder (e.g. Freidreichs ataxia or Charcot-Marie Tooth syndrome [9] ) at referral. Dead Regions Non-Organic Hearing loss or Non-organic overlay to a hearing loss Diagnosed by a TENS test or equivalent Diagnosed by an ENT doctor or an Audiological Physician. 2. Co-existing or Confounding Conditions Neurological disorder Dual sensory loss Physical impairments which restrict dexterity for hearing aids or other communication Diagnosed by Neurology. For example a stroke or head injuries. Where visual impairment accompanies hearing loss and impacts upon the person s communication ability. Poor manual dexterity, impaired sense of touch, or inability to reach ears Page 3

4 devices Learning disabilities Dementia or memory problems Psychological / Psychiatric Disorders / Psychosocial issues Diagnosed by an appropriate healthcare professional, where the nature or severity of the condition may affect the hearing rehabilitation process. [10] Diagnosed by an appropriate healthcare professional, where the nature or severity of the condition may affect the hearing rehabilitation Where the patient has a diagnosis from an appropriate healthcare professional, and where compliance difficulties or severe problems in family circumstance may affect the hearing rehabilitation process. 3. Poor Outcomes Poor outcome measured at the end of pathway Frequently attended for follow-up or fine tuning Poor discrimination of speech Failing to meet appropriate clinical expectations for treatment as indicated on page 1 of this document. Someone who has attended for 3 visits for alterations to the hearing aid settings [2] or reinstruction within 12 months. Clinical decision is dependent upon the speech test used; the appropriate guidance should be followed. Conclusion This document has identified complex types of hearing loss to help practitioners referring people with hearing loss to identify the appropriate referral route. This should ensure that patients receive accurate diagnosis and specialist support from professionals who are best able to provide appropriate management of their condition(s). It is essential that clear pathways and tariffs are established to ensure that patients received cost-effective and timely treatment Page 4

5 Bibliography [1] British Society of Audiology, "Practice Guidance: Common Principles of Rehabilitation for Adults with Hearing- and/or Balance- Related Problems in Routine Audiology Services," 30 August [Online]. Available: [Accessed 24 July 2014]. [2] NHS Improvement, "Shaping the future: Strengthening the evidence to transform Audiology services," [Online]. Available: ology/documents/shaping_the_future.pdf?fileticket=zrsxjlxtecw=&tabid=56. [Accessed ]. [3] British Society of Audiology, "Recommended Procedure: Pure-tone air-conduction and boneconduction threshold audiometry with and without masking," 24th September [Online]. Available: [Accessed 28 July 2014]. [4] G. B. Hughes, M. A. Freedman, T. J. Haberkamp and M. E. Guay, "Sudden sensorineural hearing loss.," Otolaryngologic Clinics of North America, vol. 29, pp , [5] British Academy of Audiology, "Guidelines for Referral to Audiology of Adults with Hearing Difficulty," [Online]. Available: [Accessed 24 July 2014]. [6] D. M. Baguley, "Hyperacusis," Journal of the Royal Society of Medicine, vol. 96, pp , [7] D. M. Baguley and D. McFerran, "British Tinnitus Association," August [Online]. Available: [Accessed 24 July 2014]. [8] British Society of Audiology, "Practice Guidance: An Overview of Current Management of Auditory Processing Disorder (APD)," 1st August [Online]. Available: [Accessed 24 July 2013]. [9] G. Rance, M. Ryan, P. Carew, L. Corben, E. Yiu, J. Tan and M. Delatycki, "Binaural Speech Processing In Individuals With Auditory Neuropathy," Neuroscience, vol. 226, pp , [10] L. McShea, C. Corkish, S. McAnelly "Audiology services: access, assessment, and aftercare," Learning Disability Practice, vol. 17, no. 2, pp , [11] British Society of Hearing Aid Audiologists, "Guidance on Professional Practice for Hearing Aid Audiologists," [Online]. Available: FD4C904904A6&atc=aaa&nodeid=6E26407D E-BA7D-E59BFF [Accessed Page 5

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